The Abyssinian Baptist Church

REFERENCE MANUAL
V 35 / NO 6
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Guideline on Oral Health Care for the Pregnant
Adolescent
Originating Council
Council on Clinical Affairs, Committee on the Adolescent
Adopted
2007
Revised
2012
Purpose
The American Academy of Pediatric Dentistry (AAPD), as the
oral health advocate for infants, children, adolescents, and persons with special needs, recognizes that adolescent pregnancy
remains a significant social and health issue in the US. This
guideline is intended to address management of oral health care
particular to the pregnant adolescent rather than provide specific treatment recommendations for oral conditions.
Methods
This document is an update of the guideline adopted in 2007.
The revision included an electronic search of the PubMed
database using the following parameters: Terms: “pregnancy”,
“adolescent pregnancy”, “maternal”, “pre-term birth”, “oral
health”, “low birth weight delivery”, and “periodontal disease”;
Fields: all; Limits: within the last 10 years, humans, English,
clinical trials. The reviewers selected 79 articles that met the
defined criteria to update this guideline. When data did not
appear sufficient or were inconclusive, recommendations were
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
®
Background
General considerations
In 2009, a total of 409,840 infants were born to 15 through
19 year olds, for a live birth rate of 39.1 per 1000 women in
this age group.1 While the US teen birth rate fell by more
than one-third from 1991 through 2005, it then increased by
five percent over two consecutive years. Data for 2008 and
2009 indicate that the long-term downward trend has
resumed.2 Approximately 50 percent of adolescent pregnancies
occur within the first six months of initial sexual intercourse,
even with increasing use of contraceptives by adolescents.3
The correlation between poverty and adolescent pregnancy
is great, for as many as 83 percent of adolescent females who
give birth are from low-income families.4 Once an adolescent has given birth to one child, she is at increased risk for
giving birth to another child during adolescence.5 There
exist racial, ethnic, and economic disparities related to oral hygiene practices and dental service utilization during pregnancy;
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reports indicate minority pregnant adolescents had only limited dental visits and possessed limited knowledge of oral
health and pregnancy outcomes.6,7
Medical complications involving mother and child occur
more frequently in pregnant females aged 11 through 15
years than those aged 20 to 22 years.8 These include the delivery of low birth weight infants, increased neonatal death rate,
and increased mortality rate for the mother.8 In addition,
pregnancy-induced hypertension, anemia, sexually transmissible diseases, and premature delivery are concerns for the
pregnant adolescent.9 Hypertension increases the risk of
bleeding during procedures. Blood pressure greater than or
equal to 140/90 mmHg is considered mild hypertension,
whereas values greater than or equal to 160/110 mmHg are
considered severe.10
The diet of the pregnant adolescent can affect the health
of the child. A healthy diet is necessary to provide adequate
amounts of nutrients to the mother-to-be and the unborn
child.11 Nutrients of particular importance include folate, vitamin B-6, vitamin B-12, calcium, and zinc.12 During pregnancy,
a woman’s nutritional needs are increased, but certainly the
“eating for two” concept is not recommended.13 The total energy
needs during pregnancy range between 2,500 to 2,700 kcal a
day for most women, but pre-pregnancy body mass index,
rate of weight gain, maternal age, and physiological appetite
must be considered in tailoring this recommendation to the
individual.14 Nausea and vomiting occur in 50 to 90 percent
of all pregnancies during the first trimester and often are
associated with young age and low socioeconomic status.15 An
expectant female may modify food choices due to morning
sickness and/or taste aversions, but appropriate nutrition for
the health of the mother and fetus is crucial.
The goal of any drug therapy during pregnancy is to improve maternal/fetal health while avoiding adverse drug reactions.16 Reporting that medications for pregnant patients
sometimes are prescribed under less than optimal conditions, a
study of obstetrician-gynecologists emphasizes the importance
of generating and having available to heath care providers
up-to-date information on effects of medications during
pregnancy.17 The US Food and Drug Administration has
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
defined five categories of drugs according to the risk they pose
to pregnant women and their fetuses.18 These categories provide some guidance to the relative safety of the medication for
use by pregnant women. Category A includes drugs that have
been studied in humans and have evidence supporting their
safe use; Category B drugs show no evidence of risk to humans. Generally, these drugs are considered acceptable for use
during pregnancy.16 Category C drugs, such as aspirin and
aspirin-containing products, may be used with caution,
whereas drugs in categories D (eg, tetracycline) and X are not
intended for use during pregnancy. The Organization of
Teratology Information Services provides useful national information for drug safety during pregnancy.19
Low socioeconomic status and lack of parental involvement can place an adolescent at increased risk of initiating
tobacco use.20 Smoking during pregnancy is associated with adverse outcomes.20,21 Women who smoke may have increased
risks for ectopic pregnancy, spontaneous abortion, and preterm
delivery.20,21 Infants born to women who smoke during pregnancy are more likely to be small for gestational age and have
low birth-weight.20-23 The longer the mother smokes during
pregnancy, the greater the effect on the infant’s birth weight.21
Increasing evidence shows that maternal tobacco use is associated with intellectual disability and birth defects such as oral
clefts.20 The risk for perinatal mortality (ie, stillbirths and
neonatal deaths) and sudden infant death syndrome (SIDS)
is increased for infants of women who smoke.20,21 Infants and
children exposed to environmental tobacco smoke (ie, second
hand smoke) have higher rates of lower respiratory illness,
middle ear infections, asthma, and caries in the primary dentition.20-25 Women are more likely to stop smoking during
pregnancy, both spontaneously and with assistance, than at
other times in their lives.21
Use of ionizing radiation in the US is a well-regulated
activity.26 The federal government establishes performance
standards for manufacture and installation of x-ray generating
equipment. States implement regulations that govern users;
these regulations pertain to facility design, shielding, and use
and maintenance of equipment.21 Major biological risks from
radiation exposure are carcinogenesis, fetal effects, and mutations. Health benefits will outweigh the risk from radiation
exposure from any radiographic examination if:
1. the examination is clinically indicated and justified;
2. technique is optimized to ensure high quality diag
nostic images; and
3. principles are followed to minimize exposure.26
Oral conditions associated with pregnancy
Changes in the oral cavity have been associated with pregnancy.
These include alterations in both the hard and soft tissues. An
increase in caries has been associated with carbohydrate loading as snacking becomes more frequent.11 In some instances,
morning sickness and vomiting/reflux may contribute to the
onset of perimyolysis, an erosion of the lingual surfaces of
the teeth caused by exposure to gastric acids. A confounding
factor is that pregnancy-associated hormonal changes may cause
dryness of the mouth. Approximately 44 percent of pregnant
participants in one study reported persistent xerostomia.27
From a periodontal perspective, the effects of hormonal
levels on the gingival status of pregnant women may be accompanied by increased levels of Bacteroides, Prevotella, and
Porphyromonas.28 Signs of gingivitis (eg, bleeding, redness,
swelling, tenderness) are evident in the second trimester and
peak in the eighth month of pregnancy, with anterior teeth
affected more than posterior teeth.29 These findings are exacerbated by poor plaque control and mouth breathing.29
Increased tooth mobility has been associated with microbial
shifts from aerobic to anaerobic bacteria.28 These bacterial
shifts are accompanied by increased inflammation in the
attachment apparatus, as well as mineral disturbances in the
lamina dura, causing tooth mobility. This condition appears
to reverse postpartum.28
The study of periodontitis during pregnancy and its effect
on preterm, low birth weight infants is ongoing. Early studies
noted an increase rate of preterm/low birthweight deliveries
associated with periodontal disease.29,30 However, a more recent
study of 116 postpartum women noted clinical attachment
level measures were not different between those with preterm/
low birthweight babies and control groups. Therefore, maternal periodontal microbiota and clinical characteristics of
periodontal disease were not associated with having preterm/
low birthweight babies.31
More recent studies continue to demonstrate conflicting
results.32-39 Several studies conducted in the US, including the
Oral Conditions and Pregnancy (OCAP) Cohort Study, have
shown an increased risk of adverse pregnancy outcome(s) with
periodontal disease. The OCAP studies also showed increased
odds of the adverse pregnancy outcomes of preeclampsia,40
fetal immune response,41 and very early preterm birth,42 among
other conditions. The best available evidence to date shows
that periodontal treatment has no effect on birth outcomes
of preterm labor and low preterm birthweight and is safe for
the mother and fetus.43 The effect of periodontitis and the
development of preeclampsia, a rapidly progressing condition
occurring in pregnancy characterized by hypertension and the
presence of proteinuria, continues to be studied as well.34,38,44,45
Oral health care during pregnancy
A multi-state study concluded that, besides neglecting medical
care during pregnancy, most expectant females of all ages do
not seek dental care, even though 50 percent of them have a
dental problem.9 A woman’s lack of receiving routine dental
care when not pregnant was the most significant predictor of
lack of receiving care during pregnancy.6 The expectant mother
might question the safety of dental treatment during pregnancy. Untreated oral disease may compromise the health of
the pregnant female and the unborn child.46 The consequences
of not treating an active infection during pregnancy outweigh
the possible risks presented by most of the medications required
for dental care.17 In addition, deferring elective dental treatment during a healthy pregnancy is not justified.46
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The amount of radiation exposure from dental x-rays is
very small, ranging from 0.038 millisieverts (mSv) for bitewing radiographs to 0.15 mSv for a full mouth series.47
During dental radiographic examination of a pregnant patient,
optimizing techniques, shielding the thyroid and abdomen,
choosing the fastest available image receptor (ie, high-speed
film, rare earth screen-film systems, digital radiography),
and avoiding retakes help minimize radiation exposure to the
fetus.26,48 The health care provider must be aware that the
primary dental x-ray beam may pass near or through the
thyroid gland, even with attention to proper radiographic
techniques. The juvenile thyroid is among the most sensitive
organs to radiation-induced tumors, both benign and malignant.26 Risk decreases significantly with age at exposure,
essentially disappearing after age 20.26 Evidence shows that
radiation exposure to the thyroid during pregnancy is associated with low birthweight.49 Common dental projections
rarely, if ever, deliver a measurable absorbed dose to the
embryo or fetus.26 Gonadal absorbed dose from a typical dental
x-ray procedure is equivalent to about one hour of natural
background radiation.26 The National Council on Radiation
Protection and Measurements recommends if dental
treatment is to be deferred until after the delivery, so should
the dental radiographs.26
The objectives of professional oral health care during
the first trimester include avoiding fetal hypoxia, premature
labor/fetal demise, and teratogenic effects.46 Due to the increased risk of pregnancy loss, use of nitrous oxide may be
contraindicated in the first trimester of pregnancy.50 Prevention, diagnosis, and treatment of oral diseases (including
needed dental x-rays and use of local anesthesia) are highly
beneficial and can be undertaken any time during pregnancy
with no additional fetal or maternal risk as compared to
not providing care.43 It is safe to provide dental treatment
throughout pregnancy; however, because the pregnant uterus
is below the umbilicus, the woman is generally more comfortable during weeks 14 to 20 of gestation. Pregnant women
are considered to have a “full stomach” due to delayed gastric
emptying and, therefore, are at increased risk for aspiration,
particularly during the last trimester.51,52 Elective restorative
and periodontal therapies during the second trimester may
prevent any dental infections or other complications from
occurring in the third trimester.46 In the final trimester, a
dental prophylaxis may be repeated, especially if home oral
care is inadequate or if soft tissue is abnormal.
Evidence is insufficient to support or refute that mercury
exposure from dental amalgams contributes to adverse pregnancy outcomes.53,54 Currently, there is no evidence that the
exposure of a fetus to mercury releases from the mother’s
existing amalgam fillings causes any adverse effects.53,55 Mercury
vapor released during the removal or placement of amalgam
restorations may be inhaled and absorbed into the blood
stream and does cross the placental barrier. The use of rubber
dam and high speed suction can reduce the risk of vapor
inhalation.55 Because use of tooth whitening products that
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contain or generate hydrogen peroxide results in release of inorganic mercury from dental amalgams, these products should
be avoided during pregnancy by patients who have amalgam
restorations.56
Suppression of the mother’s reservoirs of Mutans streptococci (MS) by dental rehabilitation and antimicrobial treatments may prevent or at least delay infant acquisition of
these cariogenic microorganisms.57 MS, present in children
with early childhood caries, is predominantly acquired from
mother’s saliva.58 MS generally is considered to be a principal
group of bacterial organisms responsible for the initiation of
dental caries.59 MS colonization of an infant may occur from
the time of birth.60-66 Improving oral health during pregnancy
leads to a reduction in salivary MS in the offspring.58 Beginning in the sixth month of pregnancy, a daily rinse of 0.05
percent sodium fluoride and 0.12 percent chlorhexidine has
resulted in significant reduction in levels of caries-causing
bacteria, consequently delaying the colonization of such
bacteria among offspring.57 Xylitol, a naturally occurring
sweetener, has been added to a variety of products because of
its potential to reduce caries incidence. Evidence suggests
maternal use of xylitol chewing gum (at least two or three
times a day) has a significant impact on mother-child
transmission of MS and subsequent decrease of the child’s
caries rate.67-69
Education is an important component of prenatal oral
health care and may have a significant effect on the oral health
of both the mother and the child. Counseling for the pregnant
adolescent includes topics directed toward all adolescent patients (eg, dietary habits, injury prevention, third molars), as
well as oral changes that may occur during pregnancy and infant oral health care. Since the pregnant adolescent may be
receptive to information that will improve the infant’s health,
anticipatory guidance, a proactive developmentally-based
counseling technique, can be introduced to focus on the needs
of the child at each stage of life. Studies have documented
that early oral health care promotion starting during pregnancy can lead to a sustained and long-term improvement of
the oral health of children.70,71
Legal considerations
Statutes and case law concerning consent involving pregnant
patients less than 18 years of age vary from state to state. In
some states, dentists are required to obtain parental consent
for non-emergency dental services provided to a child 17 years
of age or younger who remains under parental care.72 This
would involve obtaining consent from the parent who must
be aware of the pregnancy in order to understand the risks and
benefits of the proposed dental treatment.46 However, if the
parent is unaware of the pregnancy, the pregnant adolescent
may be entitled to confidentiality regarding health issues such
as the pregnancy.73 In other states, there are “mature minor”
laws that allow minors to consent for their own health care
when a dentist deems the minor competent to provide
informed consent. In addition, some states emancipate minors
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
who are pregnant or by court order. Practitioners are obligated to be familiar with and abide by the laws specific to
where they practice and where the patient resides.
Recommendations
The AAPD recommends that all pregnant adolescents seek
professional oral health care during the first trimester. After
obtaining a thorough medical history, the dental professional
should perform a comprehensive evaluation which includes a
thorough dental history, dietary history, clinical examination,
and caries risk assessment. The dental history includes, but is
not limited to, discussion of preexisting oral conditions, signs/
symptoms of such, current oral hygiene practices and preventive
home care, previous radiographic exposures, and tobacco use.20-25
The adolescent’s dietary history should focus on exposures to
carbohydrates, especially due to increased snacking, and acidic
beverages/foods. During the clinical examination, the practitioner should pay particular attention to health status of the
periodontal tissues.27,28 The AAPD’s caries-risk assessment
guideline74, utilizing historical and clinical findings, will aid the
practitioner in identifying risk factors in order to develop an
individualized preventive program.
Based upon the historical indicators, clinical findings, and
previous radiographic surveys, radiographs may be indicated.
Because risk of carcinogenesis or fetal effects is very small but
significant, radiographs should be obtained only when there
is expectation that diagnostic yield (including the absence of
pathology) will influence patient care.26 If dental treatment
must be deferred until after delivery, radiographic assessment
also should be deferred. All radiographic procedures should be
conducted in accordance with radiation safety practices. These
include optimizing the radiographic techniques, shielding the
pelvic region and thyroid gland, and using the fastest imaging
system consistent with the imaging task. Image receptors of
speeds slower than American National Standards Institute
(ANSI) speed group E shall not be used.26
Counseling for all pregnant patients should address:
• Relationship of maternal oral health with fetal
health43 (eg, possible association of periodontal
disease with preterm birth and pre-eclampsia),
• An individualized preventive plan including oral
hygiene instructions, rinses, and/or xylitol gum to
decrease the likelihood of MS transmission postpartum,67-69
• Dietary considerations (eg, maintaining a healthy
diet, avoiding frequent exposures to cariogenic foods
and beverages, overall nutrient and energy needs11-13),
• Anticipatory guidance for the infant’s oral health in cluding the benefits of early establishment of a dental
home,70,71
• Anticipatory guidance for the adolescent’s oral health
to include injury prevention, oral piercings, tobacco
and substance abuse, sealants, and third molar
assessment,75
• Oral changes that may occur secondary to pregnancy28,29 (eg, xerostomia, shifts in oral flora),
• Individualized treatment recommendations based upon the specific oral findings for each patient.
Preventive services must be a high priority for the adolescent pregnant patient. Ideally, a dental prophylaxis should be
performed during the first trimester and again during the
third trimester if oral home care is inadequate or periodontal
conditions warrant professional care. Referral to a periodontist
should be considered in the presence of progressive periodontal disease.28,29 While fluoridated dentifrice and professionallyapplied topical fluoride treatments can be effective caries
preventive measures for the expectant adolescent, the AAPD
does not support the use of prenatal fluoride supplements to
benefit the fetus.76
A pregnant adolescent experiencing morning sickness or
gastroesophageal reflux should be instructed to rinse with a
cup of water containing a teaspoon of sodium bicarbonate and
to avoid tooth brushing for about one hour after vomiting to
minimize dental erosion caused by stomach acid exposure.6
Women should be advised about the high sugar content and
risk for caries associated with long term frequent use of over
the counter antacids. Where there is established erosion, fluoride may be used to minimize hard tissue loss and control
sensitivity. A daily neutral sodium fluoride mouth rinse or gel
to combat enamel softening by acids and control pulpal sensitivity may be prescribed.77 A palliative approach to alleviate
dry mouth may include increased water consumption or
chewing sugarless gum to increase salivation.27
Common invasive dental procedures may require certain
precautions during pregnancy, particularly during the first trimester. Elective restorative and periodontal therapies should be
performed during the second trimester. Dental treatment for a
pregnant patient who is experiencing pain or infection should
not be delayed until after delivery. When selecting therapeutic agents for local anesthesia, infection, postoperative pain, or
sedation, the dentist must evaluate the potential benefits of
the dental therapy versus the risk to the pregnant patient and
the fetus. The practitioner should select the safest medication,
limit the duration of the drug regimen, and minimize dosage.43
Health care providers should avoid the use of aspirin, aspirincontaining products, erythromycin estolate, and tetracycline in
the pregnant patient.10 Non-steroidal anti-inflammatory drugs
routinely are not recommended during pregnancy; if necessary,
administration should be avoided during the first and third
trimesters and be limited to 48 to 72 hours.43
Patients requiring restorative care should be counseled regarding the risk and benefits and alternatives to amalgam fillings.53-55 The dental practitioner should use rubber dam and
high speed suction during the placement or removal of amalgam
to reduce the risk of vapor inhalation.55 Consultation with the
prenatal medical provider should precede use of nitrous oxide/
oxygen analgesia/anxiolysis during pregnancy. Nitrous oxide
inhalation should be limited to cases where topical and local
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anesthetics alone are inadequate. Precautions must be taken to
prevent hypoxia, hypotension, and aspiration.51
The pediatric dentist should incorporate positive youth
development (PYD)75 into care for the adolescent patient. This
approach goes beyond traditional prevention, intervention, and
treatment of risky behaviors and problems and suggests that a
strong interpersonal relationship between the adolescent and
the pediatric dentist can be influential in improving adolescent
oral health and transitioning to adult care. Through PYD, the
dentist can promote healthy lifestyles, teach positive patterns
of social interaction, and provide a safety net in times of
need. At a time agreed upon by the patient, parent, and pediatric dentist, the patient should be transitioned to a practitioner
knowledgeable and comfortable with managing that patient’s
specific oral care needs.75
Dental practitioners must be familiar with state statutes
that govern consent for care for a pregnant patient less than the
age of majority. If a pregnant adolescent’s parents are unaware
of the pregnancy, and state laws require parental consent for
dental treatment, the practitioner should encourage the adolescent to inform them so appropriate informed consent for
dental treatment can occur.
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